March 12, 2021 | Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content, innoviHealth
Because deaths due to drug overdose is a nationwide epidemic, federal, state, and private organizations created substance use disorder (SUD) programs to treat patients who abuse alcohol or other illicit substances, or who have a history of prolonged use of prescription narcotics/opioids.
The Drug Enforcement Administration (DEA) places each drug into a category known as a schedule. Each schedule classifies drugs, substances, or chemicals along with its medical value and potential for abuse. Schedule I, II, and III drugs have the highest potential for abuse, treated for in SUD programs. A list of scheduled drugs can be seen at https://www.dea.gov/drug-scheduling.
States track the number of deaths from drug-related overdoses and promote additional prevention through SUD programs such as Medication-Assisted Treatment (MAT). MAT program services are often reimbursed by federal, state, and commercial payers. As with any program, services are audited for compliance and proper coding. The best way to understand what may need to be submitted for review in an audit is to understand how these programs generally function.
MAT programs prescribe and administer methadone or buprenorphine to patients to reduce opioid cravings and eliminate dependency. Once abstinence has been obtained and maintained for a period of time determined by the patient’s individual treatment plan, the patient is slowly backed off from methadone or buprenorphine use until they can maintain their own sobriety. Counseling services are provided to patients all throughout the program for support, as use in dependency is often triggered by stressful events, and counseling and skill-building help patients manage these triggers better.
Admission paperwork must be reviewed and signed by the patient before program admittance. Program admission usually includes a comprehensive physical and mental examination, testing (e.g., hepatitis B, TB, and urine for illicit drugs), consenting to randomized drug testing, security, HIPAA, anti-diversion, payment, privacy, medication handling, and other rules and guidelines.
Medication Dose Determination and Administration
Methadone or buprenorphine dose determination is performed by the physician managing the patient’s treatment program by way of prescription. While it may be administered by the physician, usually this task is delegated to licensed nursing staff (e.g., LPN, RN). Federal and state dispensing laws must be adhered to for dose determination, administration, and take-out dose dispensing, including documentation maintained in the medical record that includes:
- A signed, written or electronically entered prescription for the drug being administered, including strength, quantity, and dose frequency.
- Documentation identifying the clinical staff member who administered the prescribed medication, including the medication name, strength, quantity administered/dispensed as take-out doses, and medication lot number (in case there was a manufacturing problem)
- Documentation of any take-out dose(s) provided to the patient, including the name of the clinical staff member who dispensed the medication, date, time, lot number, and dosing instructions for at-home use.
Urine Drug Testing
Random drug testing is a clinical tool that provides meaningful information, reinforces positive behavioral changes, and helps guide treatment. The patient will receive a call to produce a urine specimen for testing and must present within a designated timeframe or lose certain program privileges. Some patients require an observed urine specimen collection, which involves the presence of trained clinical personnel during specimen collection to ensure the specimen is from the intended patient.
Every MAT program must have the appropriate CLIA-waiver certificate to legally perform laboratory services. For the low cost, ease of use, and quick results it brings, urine is often the specimen of choice. Over-the-counter medications and certain foods can trigger a positive result and all unexpected positive results must be addressed by a physician/counselor within a designated timeframe (e.g., 7 days). Test results should only be positive for the medication prescribed for treatment (i.e., methadone or buprenorphine) or a prescribed medication approved for use by the program’s medical director.
Auditing MAT Services
Coding and auditing personnel should understand multiple documents are often required to support certain MAT services, as noted here:
Urine Drug Screens (UDS)
- Physician’s Order
- Written or electronically signed order (if available)
- A formal order is not required when performed in the outpatient or office setting, but a patient encounter note that shows the test was expected or implied should suffice
- Admission paperwork with patient consent to random UDS for illicit use/compliance based on federal, state, and individual requirement(s) is also supportive
- Test Results
- A copy of the clinic’s current CLIA-waiver certificate
- Test results including (patient name, date of service, substances tested, results, and the identity of the clinical staff member who performed the test.
- Abnormal results should include physician’s initials/date to show they were reviewed.
- Counseling Notes
- Abnormal results require immediate review by a physician or counselor
- Documentation should include the substances with positive results and any counseling associated with them
- Physician or counselor’s name, credentials and signature (e.g., electronic signature)
Audits for the actual administration of the drug should include:
- Physician’s Order
- Physician’s order (e.g., electronic prescription, written order) including signature and date
- Patient identification (e.g., name, date of birth, assigned number)
- Drug name, strength, and quantity
- Dosing instructions (e.g., tapering, increase)
- Physician’s signature and the date signed. Ensure signature requirements are met (e.g., legible)
- Patient Medication Record (containing the following)
- Date of service, patient identifying information
- Reference to the physician’s order
- Medication name, strength, and quantity
- How administered or dispensed
- Lot number of the medication for tracking purposes
- Name/credentials of the clinical staff who administered the medication
Ensuring the correct supporting documentation for review can save time and reduce poor outcomes. MAT programs are strictly governed and include a significant amount of paperwork. Submission of the right information can alleviate potential problems and create better outcomes.